Greg Hutchins
PFD Report
Historic (No Identified Response)
Ref: 2018-0129
Coroner's Concerns (AI summary)
Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.
View full coroner's concerns
(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I hear evidence that no national system exists for rapid information sharing
(6) Mr Hutchins was from outside the Birmingham area and I hear evidence that no national system exists for rapid information sharing
Sent To
- Birmingham & Solihull Mental Health Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
7 Nov 2018
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 4 September 2017 I commenced an investigation into the death of Greg HUTCHINS. The investigation concluded at the end of the inquest on 2 May 2018 2018. The conclusion of the inquest was that Mr Hutchins committed suicide.
Circumstances of the Death
Mr HUTCHINS committed suicide on 28 August 2017 in a hotel room at Day’s Inn, Corley Services Warwickshire. He had suffocated himself with a plastic bag and helium. Thirteen days earlier he had contact with the Street Triage team and I set out my concerns regarding that contact below
Copies Sent To
Aunt of the Deceased) and
(a close friend of Deceased)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.